Friday, March 14, 2008

Ten Centimeters. Push!

Last week I found myself in one of my favorite positions -- Leaning over a hospital bed, rubbing the back of a laboring mother.

Over all, the labor wasn't bad.

I went in with a positive attitude, hopeful of seeing a good birth. I liked the obstetrician - she was an extremely nice woman with a great personality, and seemed to genuinely be enjoying her job. She was very supportive of the mother's desire to have no epidural if possible. Although medical reasons made the obstetrician decide that induction of labor was appropriate, she respected the mother's wishes to keep the Pitocin drip at a minimum and not turn it up once she started contractions.

The mother had given birth in the same hospital twice previously and was well prepared for labor. Her husband was supportive and as helpful as possible.

As labor progressed and the Pitocin induced contractions became more and more unbearable and on top of each other, the nurses were awesome. They provided one-on-one care, basically having someone in the room with us constantly. They, along with the father and I, encouraged the mother to try all sorts of positions - standing, hands and knees, sitting on the birth ball, rocking, etc.

I was even more impressed when the nurses got into whatever positions they had to to continue to monitor the baby's heart rate. It seemed that whenever the mother was in an upright position, the electronic fetal monitor (EFM) just wasn't tracing the heartbeat very well. So, the nurse had to stand there for several hours continuously holding the doppler in place to maintain a tracing. There was absolutely no "I'm really busy. You'll just have to lay in bed so we can get a decent tracing" or any, "I'm sorry this isn't working. We're going to have to put in a fetal scalp electrode." (The obstetrician wanted constant monitoring because of an increased risk of fetal distress with the Pitocin induction.) Care was all focused around what the mother wanted and needed and what made her most comfortable.

I was also impressed with the information that they provided the parents with before taking any action. The mother got vaginal exams when she wanted them, not every two hours or according to any set protocol. The father and mother both didn't want her water broken early in labor. The hospital staff respected their decision and didn't do it till near the end, when the mother requested it.

As I massaged the mother's shoulders and gave the father suggestions for new ways he could support her and asked the nurses to better explain the progress to the couple, I found myself thinking, "This birth isn't bad. It's about as good as hospital birth gets."

Of course, the Pitocin made things miserable for the mother, and more than once she just burst into tears and cried, "I just can't do this anymore!" But every time she got to that point, we managed to re-focus her on dealing with this contraction and just getting through right now. Her obstetrician poked her head into the room at just such a moment, and very quietly, almost reverently watched her experiencing an intense contraction. "Wow," she whispered. "You just never see women willing to do this any more. I'm so impressed."

Ten centimeters came as the sun came up. The shift would be changing soon, but these nurses were excited that they would get to see the fruit of this labor before they left. The doctor was summoned. Mother got back into bed and was positioned in a semi-sitting position. The bed was broke down, and her legs were spread apart while the overhead lights were turned onto the site of action. The doctor gowned and gloved. Two nurses held one leg (since the stirrups were uncomfortable) and I held the other. Sterile drapes were placed everywhere, leaving only the vaginal opening exposed. The father, nervous and excited at the same time, held her hand, and reassured his exhausted, tearful wife that she was almost done. She was so tired, and kept saying, "I don't think I have the energy to push. I can't."

We all assured her over and over that she could and would get her baby out. The doctor leaned in close to her face and looked her in the eyes, "Just listen to me and do what I tell you. Just follow my instructions closely and you'll be just fine."

The mother nodded through her tears, and the father whispered, "Honey, you can do it. Just listen to the doctor.""Okay, on the next contraction...." The doctor began to explain the process of letting the contraction build, then taking a deep breath and holding it while pushing as hard as possible while the nurses count to ten.

I sighed to myself. Purple pushing. Why do all doctors think that this is the only way to get a baby out? I knew they'd do this. Why do I even hope that this time will be different?

("Purple pushing" is the above described technique, termed such by many doulas and midwives because the mother has so little time to breathe and exerts herself so intensely that she often starts to turn purple and even burst the blood vessels in her eyes. It has been employed at nearly every hospital birth I've ever attended. It barrels a baby a baby out faster than any other method of pushing. A first time mother who might take an hour to push a baby out when allowed to do it at her own pace, will usually push a baby out in less the 20 minutes with this incredibly intense way of pushing. I personally think that purple pushing can be necessary and effective if a baby is in fetal distress and there is a good reason to get the baby out as quickly as possible. If there is not medically indicated reason, I think it just traumatizes the mother's body [tissues don't have much time to stretch and she's more likely to tear, etc.] more than necessary, not to mention that she thinks of pushing as one of the hardest, most exhausting things she's ever done.)

"No, honey. Not till this contraction is done." (Pulling her forward) "Take a deep breath right now, and hold it. Hold it while I count to ten... (more insistently) ONE! TWO! THREE! FOUR...."Ten minutes have passed. We're seeing a baby's head. The doctor comments on all the hair. Mother is gasping for air between pushes and saying she needs to slow down. The Pitocin drip is still going, and the contractions are coming right on top of another.

"No, not till your baby's here. Keep going!"The nurses get in her face to help her stay with the pushing a little longer. I want to tell her she can take a 10 second break, but that is obviously not the opinion of the doctor.

I tell myself that this is ridiculous, but determine to keep my mouth shut. I'm the doula, not the obstetrician. The doc keeps taking sideways glances at the monitor. The baby's heart rate shows no sign of compromise. It's plugging away with nice short and long term variability around 140, even during contractions with head compression. Wow! The doctor smiles, "Your baby is doing great! Let's hurry up and get him out!"

The contraction ends. Mom falls back on her pillow and sobs and gasps for air. "Just... just let me rest for a minute..." I'm happy to see that the contraction is over and baby is wonderful. Surely they will let her rest till the next contraction hits. The father looks slightly concerned, torn between wanting to help his wife get what she says she needs, and wanting to follow the doctor's orders for the safety of the baby.

But, no, rest is not an option. The doctor wants to get this kid OUT! "You're almost crowning! You can't stop pushing now till your baby's head is out," she says firmly. The mother wearily sits forward, clutches her thighs again and pushes.

"No, harder, longer. Take a deep breath. Hold it while we count...." And again.... and again.

Finally a head emerges.

I breathe a sigh of relief. Finally the mother will get to inhale once without holding her breath for the count to ten.

I wait for the doctor to feel for cord around the neck. Instead she graps the baby's head firmly, locking her fingers under it's jaw line on both sides, braces her feet against the base of the hospital bed, and leans back, pulling for all she's worth. "PUSH!" she shouts at the dazed mother.

I watch with horror. The baby hasn't even rotated! How does she expect to pull the little guy out without allowing his shoulders to properly spiral through the pelvis?

The baby doesn't pop loose. Her eyes register panic. I see "lawsuit!" flashing through her mind. She yanks a little harder on the head. Still no baby. "Stuck baby!" the doctor half whispers severely to the nurses. The father has realized that the doctor is frightened and something is dead wrong. Tears squeeze out of his eyes.

"Supra-pubic pressure!" the doctor shouts in the direction of the nurse at her right shoulder. There are four nurses and a respiratory therapist standing by. Three of the nurses dive for the mother's stomach. (Supra-pubic pressure is usually applied with the palm of the hand, pressing down hard on the top of the pubic bone, trying to help the baby's shoulder "pop" out from underneath. It's a maneuver used for shoulder dystocia.)

One nurse lays the bed back flat with one swift maneuver. The other three pile onto the mother, leaning all of their weight into her stomach. She screams. "PUSH!" everyone yells together. "HARDER! HARDER! You've got to get this kid out!" The mother again grips her thighs, now having her knees almost to her ears and pushes with every ounce of strength she has left.The doctor leans back and with all of her 200 pounds, pulls on the baby as if her life depended on it.

The baby pops out. It's been less then 15 seconds since the head emerged. The doctor quickly grabs a hold of the pink, squirming body of a crying baby and suctions and cuts the cord while uttering a sigh of relief. All that scare and an APGAR of 10. The nurses straighten up, slightly shaky. The parents can't stop crying and shaking. Their little boy is here, but his arrival was the worst minute of their life.

I stand there, still holding the mother's trembling leg and rubbing it and thinking...About how this birth happened. About how it could have happened differently, if only some common sense had been used and everybody hadn't been in such a rush.

I replay every move over and over. It wasn't a shoulder dystocia. It was a little 6 lb. baby, being pushed out by a woman with a more than ample pelvis. If the baby would have been given another 30 seconds to rotate and line up the rest of his body, he would have slid out with the next push.

I shake my head, feeling sorry for the obstetrician who created her own emergency and is still shaking about the "close call" she had.

I feel most sorry for the mother and father who just went through some of the scariest moments of their life as they welcomed their baby.

The obstetrician tugs on the still pulsing cord, pulling out the placenta and throws it into a basin for pathology to inspect. She asks the nurse to turn the Pitocin up (to keep the mother from bleeding), and then inspects for tearing.

Seeing none, she looks pleased. It's been almost 5 minutes since the baby was born. He is wailing in his little warmer next to the bed. The mother is too exhausted to want to hold him right now, so the nurses are playing with him. The doctor pats her patient on the leg and says, "You look great! You'll be a little sore. Just use ice packs for a couple days. Congratulations! You have a beautiful baby!" She breezes out the door, to deliver the next patient.

I like her. She's a nice, caring woman. She's sweet and friendly. The nurses were great.

But now I know why I don't want a hospital birth. Sometimes I forget.I'll remember this one for awhile.

32 comments:

I hope that you will de-brief what really happened with your clients once they've settled in with their baby; they need to know that the scaryness was not because anything was wrong, but because the doctor was rushing the process and she panicked.

Wow! Yes, I know that feeling too well... I literally had to tell the Nurse Practioner at my birth that would not breathe and push like that. My lay midwife (acting as a doula) whispered in my ear just to push past the point I had moved the head to before (I was watching in a mirror). I was 43 weeks and I don't know but my NP tried to say he was having variable decels... but thank God she didn't try to pull him at all because he was 10lbs 1oz with a 14.5 inch nogan and he came out with his hand by his ear. Can you imagine if she had??? Please let us know how you followed up with this family. Thanks for sharing and reminding me why I hope my next will get to be a home birth like I planned the first one to be.

You really have a gift for the descriptive! As I read this story, I just felt my tension building and my stress level rising along with the family's. :( And yes, this is why I also do not want a hospital birth! Yikes!

Thank you so much for sharing this. As a doula, I can empathize (especially with the biting your tongue part). As a woman who very much wants to birth a child of her own, I also empathize - I don't want to be anywhere NEAR a hospital during labor! This story brought tears to my eyes, but it also solidified my resolve to help spread the news about physiologic pushing.

hi there, wow tense, im 33 weeks and was googling to try and fond out the right way to push, since for my first birth i was purple pushing, and i dint want to do that again ... how does one do it naturally?lovely blog, thanks xxxx

Reading this makes me OH SO greatful, once again, that *I* know enough about natural birth to know I need to bring a doula with me to the hospital. Then it also makes me rethink the whole hospital birth thing... especially after 2 homebirths!

Hi! Found your blog via a link from TammysRecipes.com - funny, I know, but she is a mom to a newborn and loves to read birth stories. I had to stop by!

I had my daughter only 16 months ago (still feels like yesterday sometimes ;)) and delivered her in the hospital. I desperately wanted a midwife, but our insurance did not cover one unless she worked within the group of practitioners that were otherwise covered. I learned the health care group had let go all the midwives 2 years earlier *sigh*. There are no birthing centers around here, and my husband was not open to having a midwife at a home delivery. *sigh* So I tried the hospital route.

They give you a "Birth Plan" to fill out and they file it away in your chart - never to be looked at again, I'm sure. Mine was never discussed and never followed, despite my numerous attempts to bring it up. My normal doctor was out at a conference, so someone I didn't even know was catching my baby. :( My water broke at 5 a.m. and since I'd had a +GBS screen, they wanted me to check in immediately (something that wasn't as urgent as they made it seem - I'm a microbiologist, even I know this). With 21+ hrs of labor, there was plenty of time to give me some antibiotics if they insisted. But I digress....

Since I wasn't progressing like they wanted (read: fast and quick), they wheeled in the Pitocin drip and hooked me up faster than you can say "Ouch!" Since I was relegated to bed, I couldn't walk as much as I wanted, nor could I use the Jacuzzi tub that would have eased the horrible contractions the Pit brought on. Ugh, they were awful! My normal contractions had been bearable, but these were a nightmare.

They started the Pit in the morning and said I might be able to come off it by 3. I was checked at 3 and had only progressed another 0.5-1 cm so they wanted to keep me on it. I was exhausted from the painful contractions that came over me in waves, so strong I could hardly breathe in between them. I felt I had no choice but to ask for an epidural, since they told me it would likely be another 12 hours before I delivered (they were right about this). There was no way I could have standed to have Pit dictate my contractions for another 12 hours - I was in agony.

My daughter was born in the wee hours of the morning with an hour of "purple pushing". By this time, I was spent. I tried to nurse her but she had swallowed a lot of amniotic fluid and was drowsy from all the medicine. :( For at least 3 months, I was so depressed about the way her birth was handled. I was angry and hurt that my birth plan wasn't even considered, it was just "whatever is most convenient for the doctor and staff". We are moving to Kentucky next week and, as I'm due in September with #2, I am anxious to find a midwife or a better doctor who will listen to my desires for a healthy birth without much medical intervention.

Wow! What a great story. I was on the edge of my seat reading this. I'm glad (and surprised) the mom didn't tear. Good for her! I've had two hospital VBAC's, and thanks to my doula and husband, I didn't have to "purple push" for either of them. I think having my husband advocating for me in this situation made a big difference.

Wow! What a great story. I was on the edge of my seat reading this. I'm glad (and surprised) the mom didn't tear. Good for her! I've had two hospital VBAC's, and thanks to my doula and husband, I didn't have to "purple push" for either of them. I think having my husband advocating for me in this situation made a big difference.

Just thought you might like to read my birth story. Actually, it's 2 births, each at the same hospital, nearly 2 years apart with nearly opposite results (other than a healthy baby). A great natural birth can happen at a hospital, but it takes very willful, prepared parents and willing medical folks.http://sonshinecottage.blogspot.com/2007/06/birth-story.html

One of the best things I loved about having a doula was having someone to talk to about my births, the bad and the good.

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i think what mommymichael hit on is important - this is another story that people will pass around, at least in their hearts and heads, as one of "those" stories. THANK GOD FOR DOCTORS otherwise the babies wouldnt have a chance! it's so so sad and i also hope you took some time to speak with your clients about the truth.

i am so thankful that i chose to deliver my second child at home. my first was born in a hospital with a nuchal arm and they were very freaked out by this. my daughter was brow presenting and im sure i would have been cut ten ways to tuesday had i been under the "care" of an ob vs a CPM in my kitchen. now THAT was some purple pushing (but with purpose) i burst every blood vessel in my face getting her out but it was still under my own control. she just had a huge noggin coming out malpresenting!

safe for work!http://img.photobucket.com/albums/v414/SoftLetters/Olive/eight.jpg&http://img.photobucket.com/albums/v414/SoftLetters/Olive/five.jpg

This sounded very similar to my first birth. It was "mostly natural", no epidural, pitocin, monitor, or IV, mainly because I arrived at the hospital at 7 cm and quickly transitioned. I made 2crucial mistakes. One, I allowed the doctor to give me a local anesthetic before pushing "just in case" I needed an episiotomy. Two, because of the local, I pushed very enthusiastically. My baby was out in 25 minutes. I needed a couple of stitches, but what I didn't realize at the time, I also had many tiny tears in the perineal tissue. Four days later and I was clutching the walls and gasping for air whenever I urinated. It was more painful than the birth. In tears, I asked to be taken to the emergency room. Hours later and I was diagnosed with a bladder infection. I blamed it on the tissue damage which opened my body up to infection. My next birth was at home and was actually harder. The baby was poorly positioned and the midwife put me through all sorts of gyrations to loosen him up. Still, when it came time to push him out, I did it gently and slowly. I was on all fours, and seriously my hands and knees hurt more than my bottom. The 2nd baby outweighed the first by almost two pounds. I had no tearing and NO post-partum pain.

I believe that hospitals are only interested in getting the baby out as fast as possible because it's much easier to handle a patient ex-utero. They have no concern at all for your post-partum recovery.

I generally try not to comment on stories like this but I can't help it...

The story itself was fine but some of the comments that follow it up are ridiculous!

I work labor and delivery at a local hospital and we're NOT all about getting the baby out fast without regard to the mother or baby. It's a load of crap to suggest we're ALL like that.

Reading about the women who decide after the delivery about what the doctor should and shouldn't do when THEY haven't been to medical school really steams me too! We do the best that we can do, in a difficult field, trying to keep our mothers and babies safe. For you random know-it-alls to suggest otherwise is narrow minded and unfair. Not that you care about fair.

You try carrying a tiny body to a cold room in the back of a ward and wrapping it up to prepare for the long journey to the morgue and then tell me how we should do our job. We do the things we do for a reason. A reason even YOU might not know.

Hospital births might not be everything you want them to be but we keep people from dying EVERY DAY! Cry, bleed, and mourn for our patients, day in and day out and then talk to us.

The first hospital birth I ever attended was similar in the way that it was "as good as a hospital birth can be". Everyone was respecting the mother's wishes, the doctor was supportive and the mom was doing great on her hands and knees on the bed. The baby starts crowning and they send for the doctor. What happened next completely affected the entire quality of the birth. Instead of the baby continuing to come gently like I'd seen at the homebirths I'd attended the doctor comes in holloring hello and insists that she flips over. She says she can't and she's in the perfect position . He says she has to and has the husband help her flip her. The mother who was once steadily, and calmly working her way through was no disrupted and started screaming. When they lay her on her back she says "NO!" and puts one hand on the doctors shoulder and her other hand on her husband's shoulder and pulls herself up into a squatting position. GREAT! I think.

The doc gives a strong NO and actually pushes her down.

She is now screaming and hollering except she thinks her pain is from birth, but I know that it's from oppression and abuse.

What a great post! You really have a wonderful perspective as a doula!

To all the commenters- please remember that the way YOU gave birth is not the one right way. The right way to give birth is the one that keeps you and your baby happy, safe, and healthy.

I chose to give birth in a hospital with a midwife. I chose to not have an epidural or any other anesthetic. Does that mean I'm better than my friend who had a spinal block or a worse mom that my friend who had a homebirth? Nope. Let's not start the mommy wars, okay?

Wow. Reading this reminds me of how extremely thankful I am for the wonderful midwife the Lord led us to and for the peaceful, calm, and joyful home water birth we were able to have! Thanks for sharing!Oh, and if you were my doula, I would have wanted you to say something about the pushing!!!!! Just a thought for next time, if it seems appropriate at the time to do so!

OMG! You could've been at the birth of my son, that is almost exactly what happened to me! I'm 20 weeks ish with my second, I'm doing as much research as I can on natural births to stop it happening again

i know this was a long time ago, but i wondered as i read it why you, the doula, didn't say more.

i don't understand.this mother was paying you to stand up for her and help her when she was most vulnerable.

why didn't you give her another option when she was pushing?why didn't you tell the doctor to wait a minute before pushing the rest of the baby out, or cutting the cord, or encourage the mother to hold her baby immediately after birth...i know it might be uncomfortable for you to be a lone voice in the delivery room-- but isn't that what a doula is for?

i wonder if you would do things differently now?

just reading this story makes me want to be a voice for that woman... isn't a doula supposed to be that voice?

Unfortunately, as a doula, I cannot "take over" in the delivery room. It is not my place to tell the doctor what to do, or to ask him/her to not cut the cord, stop pulling on the placenta, or whatever. I think that many people have the mistaken idea that they can hire a doula to speak FOR them and to argue with the doctors and nurses, when in reality, it must be the parents themselves who refuse procedures or ask for things. I cannot refuse a c-section or amniotomy for the mother. She must do it herself, as much as I would *like* to do it for her sometimes!

I can help facilitate those discussions, or whisper in her ear what she might want to say or remind her that she wanted to say "no" to this. And frequently I talk out loud to the mother, saying things that I actually want the doctor or the nurse to hear. I also ask the doctor leading questions to help the mother out at times.

But to get in the doctor's face and tell him/her to stop doing something... that is not my job.

I did and do whisper things in the mother's ear like, "It's okay; you can breathe.... There's not such a big rush to get this baby out", but when 5 people are yelling at her, it's a little hard to concentrate...

I do talk to parents about this scenario likely to happen ahead of time, telling them that if *I* really see an emergency, I will join the doctors and nurses in firmly telling them to push harder and faster. And I tell them that if I am just calm and not encouraging the pushing, they can assume that I'm not worried!

I have been researching the internet regarding "purple pushing" and found this article. What can I say - I sustained severe nerve damage to my legs and cannot walk after almost 4 hours of such pushing. Its been 3 months. Several hard falls later, sleepless nights, lots of physical therapy, tears and heart ache, the nerves are slowly growing back and I am learning to walk again. There should be some more awareness about this dangerous method of pushing. to have a newborn baby and this is just an unimaginable psychological trauma. i will never look back on this days with happiness. i am scared and scarred for life. please whoever is about to have a baby and is reading this, do prepare better for the birth.

I was dismayed that you described seeing a mother's look of fear and 'saw lawsuit!' How insulting and presumptive to assume what she is thinking, particularly the idea of a lawsuit when those, such as me, who have been in such situations are usually desperately praying and thinking about the health and well-being of her child, not something as superficial as a lawsuit.

Jen..How many babies have you lost in the delivery room? Just curious about your track record. Also I believe it's a patient's right to be able to vocalized their discontent with their practitioner's methods of delivering their children..We women ask for assistance and guidance during our labors only to have hospital staff like yourself criticize and insult us. -("The know it all's") I assume your are speaking of yourself given your flailing around of your medical diploma. How many patients have you lost again?

About Me

I am passionate about making every birth the best it can be for every woman and her baby, whether that be hospital, birth center, or home.
I believe the first step to better birth is women who are better educated... about their bodies, their incredible abilities, their choices, and the joy of motherhood.
I have been a birth activist and hospital doula for years, and now proudly claim the title of Certified Professional Midwife as well, serving women who choose homebirth.

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Disclaimer

Each of us is responsible for our own health and well being. The information and recommendations on this blog are not medical advice.The blog posts are based on the knowledge, research, and experiences of the blog author and owner. Each mother, baby and pregnancy are unique, and the blog author can assume no liability for the use of the information published on this blog. All blog readers are encouraged to do their own research and to seek appropriate medical consultation and care whenever indicated.It is a sign of wisdom, not cowardice, to seek a second or third opinion.

The suggestions in the comments section have not been endorsed or recommended by the blog author in any way.

Details have been changed to protect the identity of clients in birth stories I tell, in accordance with HIPPA regulations.

All material on this blog is copyrighted and may not be used, reprinted, etc., without permission of the blog owner.(c) 2008 Mary Ueland